As part of its effort to improve Medicare Payment Reform, the American Medical Association (AMA) is providing tools for physicians to better understand and meet the reporting requirements under the new Quality Payment Program from CMS. The AMA has created a “One Patient, One Measure, No Penalty” campaign to help physicians understand the reporting requirements and avoid the 4 percent penalty for not reporting under the Merit-Based Incentive Payment System (MIPS) track. Along with this campaign, the AMA has created an interactive MIPS Action Plan that provides deadlines and a step-by-step plan of how to meet the reporting requirement deadlines.

As part of the “One Patient, One Measure, No Penalty” campaign, the AMA has provided a short video that demonstrates how to fill out CMS forms to accurately report a quality measure on a patient encounter. A step-by-step guide is also provided as a supplement to the video, along with a sample form to review. There are also links to other tools, such as the CMS Quality Measure Search tool, so that all of the resources are available in one easy-to-find location.

The MIPS Action Plan is a ten-step plan that begins with a determination of whether MIPS applies to the physician. The AMA provides a detailed breakdown of some of the determining factors, such as whether a physician is considered a hospital-based physician, in a frequently asked questions supplemental resource. The MIPS Action Plan then proceeds to walk through the process of reporting, including deadlines to start reporting, and submitting 2017 MIPS data.

For the 2018 performance period of the Quality Payment Program (QPP), a program designed to reform Medicare payments to physicians to improve the quality of care provided, physicians will have additional opportunities to join two Advanced Alternative Payment Models (Advanced APMs). The Next Generation Accountable Care Organization (ACO) model and the Comprehensive Primary Care Plus (CPC+) model will accept new applications for participation early in 2017. Once new applicants are accepted, CMS expects that 25 percent of QPP participants will be part of Advanced APMs for performance year 2018 and eligible to receive incentive payments from Medicare.

The QPP is part of CMS’ implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10), which builds on measures created by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). It consists of two tracks for eligible professional participation: Advanced APMs and the Merit-based Incentive Payment System (MIPS). To participate as an Advanced APM, the eligible professional must be part of certain payment models, including the Next Generation ACO and CPC+ models, both of which were created by the CMS Innovation Center, which was established under section 3021 of the ACA.

The announcement that both models will open for applications in early 2017 follows promises made by CMS two months ago (see New alternative payment models announced by CMS, October 26, 2016). As part of its announcement, CMS released a Fact Sheet on the CPC+ Payer and Practice Solicitation. The American Medical Association (AMA) commended the expansion, saying that, because of Advanced APMs, “physicians will have more time with patients and more flexible payments to support care coordination and improvements in access and quality.”

The Medicare-Medicaid Accountable Care Organization (ACO) Model, an effort to improve the quality of care and lower costs for beneficiaries who are enrolled in both Medicare and Medicaid, has been announced by CMS. Current Medicare ACOs often do not have financial accountability for the expenditures of Medicaid beneficiaries attributed to their organization. The new Medicare-Medicaid ACO Model is designed to build on current Medicare Shared Savings Program (MSSP) ACOs by allowing MSSP ACOs to take on accountability for the quality of care and both Medicare and Medicaid costs for Medicare-Medicaid enrollees (also known as “dual eligible beneficiaries”).

Background

Medicare ACOs are made up of groups of doctors, hospitals, and other health care providers and suppliers who come together voluntarily to provide coordinated, high-quality care to the original Medicare fee-for-service beneficiaries. Section 3021 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) created the Center for Medicare and Medicaid Innovation, which provides for the testing of innovative payment and service delivery models. The MSSP (established by ACA section 3022) and other ACO initiatives were created to change the incentives for how medical care is delivered and paid for, moving away from a system that rewards the quantity of services to one that rewards the quality of health outcomes.

The new model

According to a CMS fact sheet, The Medicare-Medicaid ACO Model will allow new and existing MSSP ACOs to take on accountability for the full spectrum of Medicare Part A, Part B, and Medicaid costs for their patients. If Medicare-Medicaid ACOs in a state generate Medicare savings for their Medicare-Medicaid enrollees, states (as well as the Medicare-Medicaid ACO) may be eligible to share in those savings with CMS. States may choose from three options for when to begin the first 12-month performance period for the Model ACOs in their state: January 1, 2018; January 1, 2019; or January 1, 2020.

Through the Medicare-Medicaid ACO Model, CMS also seeks to encourage participation from safety-net providers in alternative payment models. Medicare-Medicaid ACOs that qualify as “Safety-Net ACOs” will be eligible to receive pre-payment of Medicare shared savings to support the ACO’s investment in care coordination infrastructure.

Eligibility and application process

CMS is accepting letters of intent from states that wish to work with CMS to design certain state-specific elements of the model, such as the details of the Medicaid financial methodology and shared savings/shared losses arrangements, selection of additional quality measures, and additional ACO eligibility requirements. States will also have the option to include additional Medicare-Medicaid enrollees not assigned under the MSSP and Medicaid-only beneficiaries in the target population for the Model.

CMS will enter into participation agreements with up to six states with preference given to states with low Medicare ACO saturation. Once a state is approved to participate in the model, a request for application will be sent to ACOs and health care providers in that state.

In addition to applying to participate in the Medicare-Medicaid ACO Model, ACOs will be required to apply to participate in the MSSP and ultimately sign a participation agreement to participate in the MSSP in order to participate in the Medicare-Medicaid ACO Model.

The trial of an alternative payment model designed to incentivize “health care value and quality, with a focus on health outcomes, under the same payment structure for the majority of” Vermont health care providers throughout the state, including Medicare, Medicaid, and commercial health care payers, will begin on January 1, 2017, and end on December 31, 2022. According to CMS, the goal of this payment model, known as the Vermont All-Payer Accountable Care Organization (ACO) Model, is “to deliver meaningful improvements in the health of a state’s population by transforming the relationships between and amongst care delivery and public health systems across Vermont” (see HHS delivers on alternative payment model promises ahead of schedule, Health Law Daily, March 4, 2016). The Vermont All-Payer ACO Model builds on the Maryland All-Payer Model by bringing statewide health care transformation beyond the hospital (All-payer system helps Maryland keep cost growth below federal level, Health Law Daily, July 22, 2016).

The Vermont ACO model will be in effect for six performance years (PY0-PY5), each spanning a full calendar year. CMS will provide start-up funding of $9.5 million in 2017 to support care coordination and collaboration between practices and community-based providers. Vermont will be accountable for statewide health outcomes, financial, and ACO scale targets across health care payers. CMS also approved a five-year extension of Vermont’s section 1115(a) Medicaid demonstration, which enables Medicaid to be a full partner in the Vermont All-Payer ACO Model.

According to CMS, “the Vermont Medicare ACO Initiative is considered a Medicare Advanced Alternative Payment Model for the providers in the two-sided risk Medicare ACO portion of the model within CMS’ Quality Payment Program, and physicians and other clinicians participating in the Vermont Medicare ACO Initiative may potentially qualify for the Advanced Alternative Payment Model bonus payments starting in performance year 2018.”

Although ACOs will continue payer-specific benchmarks and financial settlement calculations, the ACO design will be aligned across payers. Vermont payers and providers will be encouraged to participate in ACO programs with a goal of attaining 70 percent of all residents, including 90 percent of Vermont Medicare beneficiaries, participating in an ACO. Vermont’s ACO Model will help CMS attain itsgoal of “having 50 percent of all Medicare fee-for-service payments made via alternative payment models by 2018” (see New alternative payment models announced by CMS, Health Law Daily, October 26, 2016).

In terms of the financial target, Vermont will limit the annualized per capita health care expenditure growth for all major payers to 3.5 percent and the Medicare per capita health care expenditure growth for Vermont Medicare beneficiaries to at least 0.1-0.2 percentage points below that of projected national Medicare growth.

Vermont identified four priorities for its Health Outcomes and Quality of Care target: substance use disorder, suicides, chronic conditions, and access to care. Each of the priorities will be measured in three categories: (1) population-level health outcomes regardless of whether the population seeks care at the providers in the ACO; (2) health care delivery system measures and targets primarily related to the performance of care delivered by the ACO; and (3) process milestones measurable during the early years of the Model that would support achievement on the population-level and health care delivery system measures and targets.

Medicare ACO Initiative

The CMS Medicare Fee-for-Service ACO initiative that is offered by CMS to ACOs in Vermont has been tailored for the Vermont All-Payer ACO Model. The Vermont Medicare ACO Initiative is based on CMS’ Next Generation ACO Model and will support ACO design alignment with other Vermont payers’ ACO programs. Participants in the Vermont Medicare ACO Initiative may not participate in the Medicare Shared Savings Program simultaneously.

Medicaid

The section 1115(a) Medicaid demonstration promotes delivery system and payment reform by allowing Vermont Medicaid to enter into ACO arrangements that align in design with that of other health care payers in support of the Vermont All-Payer ACO Model. For more information on Vermont’s section 1115(a) Medicaid demonstration extension see Fact Sheet and CMS Approval Letter.